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APPLICATION FOR SANITATION PERMIT Permit No. ---- Date (Complete in Duplicate) _ a e ]ssued .__� 4 PArlical-ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described, d This application is made in compliancetwith County Ordinance No. 549. - JOB ADDRESS AND LOCATkON..0S-------- ------ -(---------- ---------------- -----------------.....----------------------------------•----------------------------------�-------- Owners Namet -i----�r--`-� Phone._.. T ----••----- -------------------- -------------- Address ---- ... -"---- e----- ----------------------------------------------------- Contractor's Name__ .. �___. Phone --- ---- - -------------n---------------- A 4--1- --- Installation will serve: .Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court p Motel ❑ Others-� Number, of living units: I---- Number of bedrooms __I___ Number of baths J____ Lot size 6G'_----IC___/___2-_E----------------____________ Water Supply: Public system &--Community system ❑ Private ❑ Depth to Water Table3_r ft. Character of soil to a depth of 3 feet: -Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No A--•New Construction: Yes-?�-� ( � t TYPE OF INSTALLATION AND SPECIFICATIONS: { (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-Distance from fouMaterial____ ___ ____---__--. No. of compartments-------7-------------Size-_-7G'__X__ [_f7------Liquid depth_Y�---------------Capacity---941,---------- Disposal Field: Distance from nearest well -. __Distance from foundation___r]!____._.Distance to nearest lot IineZG'________- ENuImber of lines----------r/---- - --------- .Length of each line----. G7-- —------.-.Width of trench.--�-Y------------------------ Type of filter materiaL_��.____. J _Depth of filter material-----fe --------Total length_________________________________________ r Seepage Pit: Distance to nearest-weld. -_____Distance om fo ndation--- ---G--------.Distance to nearest lot lina—.0.___________ Number of pits---__.? ____..__..__Lining material---___r _ Sixe: Diameter-23 !----------------------- Cesspool: ---__________________Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- ❑ Size: Diameter-------------------------- - -------Depth--------i--------------------------------------:----Liquid Capacity-- -------------------------gals. Privy:l Distance from nearest well__-----_--------------_-------`----------------Distance from nearest building-----------------,________________-__:_,�-0 ❑ - Distance to nearest lot line------------------------------------------------------------------•-••------------------------------------------------------------------------ Remodeling and/or repairing {describe):--- y---------• -------------------------------------------------------•-_------------------------••-------------------------- - ----------------------•-............ -------•-------------------------------••-•-----------------------------._.....------------------------------------• ------------------------------------------ --------------------------------------------------•------------------------------------------...-----------•------------------------•------------------------- •---------------- ! hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ( , ordinances, ate,laws; and rules and regulations of the San.Joaqu'nLocal Health District. \I\ _ A V (Signed) -- ( der Contractor) l By:..... r!�____ _� ----'------------------_------------ (Ti+le) � '^�� -- ----------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--=------------------------ ---- --------------- ------------------------ ------ DATE----- REVIEWED BY = = DATE ---------- BUILDING PERMIT ISSUED------------------------------ '`� DATE----------•------------ - - Alterations and/or.recommendations: -•------- ------ - ----------- ---------------------------------------------------------------------------•--` �4� ------------ ------------------------------------------------------------------------------------------ -----------------------•-------------------•-• -----------•----------------------------------------------••--------------------- -------------------------------------•--------------------------- ----- ------------------ -------------------------------------------------------------------------------------------•----------------------------------- FINAL INSPECTION BY: = Date_-.: ----ly------- �. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street q Stockton, California Lodi, California Manteca, California Tracy, California �1 ES-9-2M Revised W-2100 l